American Forum Op-Ed

TENNESSEE EDITORIAL FORUM

By Raymond H. Feierabend, MD

It’s no secret that the individual mandate is one of the most unpopular and controversial aspects of the new health care reform law.

It’s being challenged legislatively in the Tennessee General Assembly, and legally through lawsuits such as the one recently ruled on in Virginia. Two thirds of Americans say they would like to see a repeal of that provision of the law. Yet, seven in 10 Americans favor restrictions on insurance companies’ ability to deny coverage to those with pre-existing conditions and to rescind coverage when individuals become ill. Unfortunately, as long as our health care system is based largely on the private insurance industry, we can’t have one without the other.

Politically, passage of comprehensive health care reform would not have been possible with active opposition from the industry. Repeal of the individual mandate alone at this time would be vigorously opposed by health insurers and most health care providers, including hospitals and large health care systems.

Economically, without an individual mandate, the cost of insurance for those in individual and small group markets would continue to skyrocket. As the cost of premiums continues to increase, those who are young and healthy would be more likely to opt out, while those who are older and sicker would have a greater need to stay in the system.

As a form of risk management, health insurance limits each individual’s liability by spreading the cost amongst all those who are insured. The larger the pool of those contributing, the more predictable the costs incurred and the lower the premiums needed to adequately cover those costs. It works only if there is a large enough pool of healthy, lower risk individuals paying premiums into the system. If most of those who participate are ill or at high risk of becoming ill, then the cost of coverage for each individual will be much higher. If individuals wait to begin paying premiums until they become ill, they will reap the benefits of the insurance without having paid into it while healthy.

Most of those who refuse to pay for health insurance even when they are capable of doing so are simply gaming the system. They are willing to take the chance that they won’t get sick; if and when they do, it’s unlikely that they will be able to purchase insurance. But that doesn’t mean that they won’t be taken care of when necessary. If they become seriously ill or have a serious injury they will receive medical care, even if they are unable to pay for it themselves. Most hospitals and emergency departments have moral and legal obligations to provide emergency and lifesaving care to those in need, regardless of their ability to pay.

In 2009, community hospitals in this country provided over $39 billion in uncompensated care; more than half of all emergency room care in this country is uncompensated. Once an uninsured individual has exhausted their own resources, which doesn’t take long for most folks with a serious illness or injury, those who are insured and/or pay taxes end up paying for them. By not requiring everyone who is capable to pay into the system, we allow such folks to take advantage of our expensive health care system without paying for it.

There are only a couple of ways to prevent individuals from abusing the system in this way. First, we can require that everyone participate in the system, either by having insurance or by paying a tax or penalty. This can be accomplished via a single payer system supported by taxes, or by including an individual mandate in the current system. Second, we can require those who are able to obtain insurance but choose not to, to sign a waiver foregoing all medical care that is not paid for up front. Hospitals, emergency departments, physicians and other providers of health care services would then be free to deny any care that isn’t paid for, regardless of the seriousness of the condition.

But is that really the kind of health care system we want in this country?
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Dr. Feierabend is a professor with the Department of Family Medicine at James H. Quillen College of Medicine at East Tennessee State University.
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Copyright (C) 2011 by the Tennessee Editorial Forum. 2/11

AMERICAN FORUM

By Jennifer S. Smith, Ph.D., M.P.H.

Kristen Forbes of Noblesville, Indiana, had recently graduated from college when she was diagnosed with invasive cervical cancer at age 22. After a yearlong, painful battle, she succumbed to the disease, leaving behind a bright future and grieving family members and friends.

Like most of the 4,000 women in the United States who die of cervical cancer each year, Kristen’s death was preventable. We now have the medical know-how and the tools to stamp out this major cancer once and for all. What we need now, as our country honors National Cervical Cancer Awareness Month this January, is the will among members of the public health community – government officials and policymakers, medical professionals, insurers, women and others – to make it happen.

Cervical cancer used to be the leading cause of death for women in the U.S. With widespread use of Pap test screening in the last 50 years, cervical cancer rates have declined significantly, but have leveled to about 12,000 cases each year. This disease should be relatively easy to prevent. We know it’s caused by the human papillomavirus, or HPV, a common sexually transmitted infection. Most HPV infections go away on their own, but persistent HPV infections can lead to cell changes that can progress to cervical cancer. Fortunately, with proper treatment, the disease can usually be stopped before cancer develops.

The HPV vaccine is now available and prevents infection from the two types of HPV that are responsible for 70 percent of all cervical cancers. We have an established screening tool – the Pap test – that identifies cell changes that can signal cervical disease or cancer. We also have newer technology – the HPV test – to help identify women who are at increased risk.

So how can we make sure no more women die of cervical cancer?

First, we need to increase HPV vaccination rates. The HPV vaccine is recommended for routine administration in girls ages 11 and 12, with a “catch up” provision for those up to age 26. Studies show, though, that less than one in two young adolescent girls has received it.

We also need to increase screening rates. At least half of all cervical cancer deaths are due to a lack of screening. Yet about 25 percent of women in the U.S. have not been screened in the past three years. Importantly, women who have been vaccinated still need to be screened to protect against HPV types not targeted by the vaccine.

Also, while the Pap test has led to a dramatic decrease in cervical cancer in the U.S., about one third of cervical cancer deaths are caused by screening errors with the Pap test, a problem that more sensitive HPV DNA testing could address. The HPV test is available, in conjunction with a Pap test, for women ages 30 and older.

Most importantly, we need to make cervical cancer prevention a top national health priority. Public health officials and policymakers should support--and fund--programs to educate women about this disease and enable them to access prevention and treatment services. Medical professionals should educate their patients and provide these services, and insurers should pay for them. Women must take charge of their health and get screened and ensure that their adolescent daughters get vaccinated. All of these groups’ efforts must be coordinated for maximum efficiency and impact.

The elimination of cervical cancer is an eminently achievable goal. To achieve this vision, a new program – Cervical Cancer-Free America (www.cervicalcancerfreeamerica.org) – is driving state and local prevention programs, and ensuring that successful strategies are shared among the states. The initiative is led by the University of North Carolina at Chapel Hill’s Gillings School of Global Public Health.

Since the initiative’s launch last year, six states – Alabama, California, Indiana, Kentucky, North Carolina and Texas – have already joined the effort to become “cervical cancer-free.” Major universities and other public health experts are leading the charge in each state, supported by government and other leaders.

The movement to eradicate cervical cancer is gaining momentum in our country. But there is more work to be done. Let’s join hands and work together to ensure that no more women like Kristen Forbes lose their lives to this preventable disease.
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Smith is director of Cervical Cancer-Free America.
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Copyright (C) 2011 by the American Forum. 1/11

NEW MEXICO EDITORIAL FORUM

By Margarita Mercure Hibbs

Living in rural regions supports a lifestyle that many families, small businesses and retirees appreciate. However, securing access to affordable, quality health care -- especially during a recession -- can be a challenge. With roughly one-third of its 2 million residents living in rural areas, New Mexico has an especially severe challenge.

According to studies by the Rural Health Research & Policy Center, the Flex Monitoring Team, and Kaiser, there are 42 hospitals in New Mexico, only 29 of which are located in rural areas, and six of which are critical access hospitals.

What does this mean for rural New Mexicans? These numbers show that although they occupy the largest geographical territory in the state, folks in rural New Mexico only get about half the medical resources. These statistics are devastating to our state and are completely unsustainable.

Adding to the special challenges facing New Mexicans is the fact that our state has some of the highest unemployment and uninsured rates in the nation. The rural-urban disparity in insurance coverage is exacerbated by the fact that incomes are generally lower and fewer rural companies offer private health insurance.

These special challenges are why the changes brought about by the Patient Protection and Affordable Care Act are so important to New Mexicans. The Act addresses many of the health care issues that so many rural Americans face and ensures that they will now have affordable access to necessary health care that was once unavailable to them.

Historically, rural New Mexicans faced with catastrophic injuries or illnesses have had a greatly diminished chance of survival due to the lack of emergency, urgent care, and first responder resources.

The Patient Protection and Affordable Care Act creates a system that is fair for rural communities -- one that will grow rural health care workforces by making necessary investments in training, recruitment and facilities, so that rural populations have greater access to doctors, nurses, dentists and paramedics.

Health care reform sets important guidelines which address the care of our most vulnerable members of society. Under the Act, people with pre-existing conditions, children and youth, small businesses and seniors will be the first groups to directly benefit.

Beginning in 2104, insurance companies will finally be held accountable and may no longer refuse coverage to a person simply because he or she has a medical history. Until then, a pre-existing condition insurance plan serves as a bridge to meet the needs of those individuals who have already been denied insurance coverage and have been uninsured for at least 6 months.

Children can’t be denied coverage for any reason and family coverage will be extended for young adults through the age of 26.

Seniors, who have fallen into the prescription coverage gap (the “donut hole”) since 2007, will receive assistance with paying for medications, and will also have access to cheaper ones.

Most importantly, everyone will also have greater access to preventive care, which will help avoid expensive and unnecessary treatments later.

Establishing a fair playing field for small and independent businesses is a key component of reform. In New Mexico, agriculture and tourism are cornerstone industries – related small businesses contribute greatly to the economy. But typically, in rural areas, one large insurance company dominates the market, so there is no guarantee of choice or competitive pricing.

To remain viable, these small businesses must be able to attract and keep good employees by being given the opportunity to provide health insurance (large corporate businesses currently pay, on average, 18 percent less for comparable insurance plans). In the past, only 35 percent of small business owners were able to offer health insurance to their employees, but this year, more than 88.9 percent of New Mexico small businesses (24,800) with fewer than 25 employees will be eligible for tax credits to help pay the cost of necessary employee health insurance coverage.

Many New Mexicans are already benefiting from reform. Health Action New Mexico, a statewide health advocacy organization, provides information to folks in order to better explain what the health care plan does and doesn’t do. Access to this information is an important piece of reform, so we strongly encourage you to contact them directly at www.healthactionnm.org or (505) 867-1095.
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Hibbs is a rural advocacy specialist and former first lady of Estancia.
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Copyright (C) 2010 by New Mexico Editorial Forum. 10/10

MISSOURI FORUM

By Dr. Stephen Radinsky

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Radinsky is a retired radiologist.
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Copyright (C) 2010 by the Missouri Forum. 6/10

TENNESSEE EDITORIAL FORUM

By Tony Garr

We are facing tough times. We’ve faced them before and pulled our neighbors and ourselves through by making people a priority. This is what the state needs to do now.

More than a quarter million Tennesseans have lost their jobs and their health insurance since the recession began. It is estimated that more than a million Tennesseans are uninsured and have few options for changing that in the near future. Yet, the state seems determined to continue to whittle away at public health programs that combine to serve as the medical safety net. It’s time to get our priorities straight.

Times are tough in each state, yet Tennessee is the only state to cease enrollment in the Children Health Insurance Program, which we call CoverKids and is viewed as a good program by policymakers from both the Right and Left. Forty-nine other governors understand that this is not time to be blocking health care coverage for children of low- to moderate-income working families. Tens of thousands of Tennessee children are eligible for CoverKids and Tennessee gets three federal dollars for each state dollar it invests in the program, so closing it to enrollment is simply penny-wise, pound foolish.

The state has promised since 2005 to reopen the Medically Needy (aka Spend Down) TennCare program. This program is designed as a bridge, like COBRA, for eligible children, elderly, caregivers and those with disabilities to get a year of TennCare after they spend a significant portion of income toward medical bills; thus, they “spend down” to eligibility. It’s estimated that this program would help about 100,000 Tennesseans facing medical debt and lacking coverage.

Also, the state must not continue viewing county jails as part of the mental health safety net. Cuts to state mental health programs passes a huge burden onto local governments, which have neither the financial nor medical means to deal with the complexities of mental health services. State cuts to mental health result in a system that is throw-back from a century ago, with people with mental health challenges being locked up rather than receiving the compassionate and effective care we have come to know as a basic human right.

Tennessee has a $400 million TennCare Reserve and $700 million Rainy Day Fund. For too many years the state has siphoned the TennCare Reserve to shore up other areas of the state budget while losing out on the 2-to-1 federal match. This year the state must get its priorities straight and use monies designated for TennCare to reopen the Medically Needy category which the administration has been promising to do this since 2005.

It has been raining on Tennessee’s working poor for a long time, now is the time to provide families and individuals with some shelter from rain. Let’s invest some of the Rainy Day fund into the medical safety net to help communities with physical and mental health services.

A state budget, like any budget, is about priorities. This year, let’s make vulnerable Tennesseans a priority. The good news is that, despite tough times, we have a TennCare Reserve and a Rainy Day Fund, both designed to be there to meet human need in tough times. So, let’s do the wise and decent thing and use them for their intended purposes.
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Garr is executive director of the Tennessee Health Care Campaign.
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Copyright (C) 2010 by the Tennessee Editorial Forum. 1/10

By Susan Wysocki and Susan Scanlan

It’s not surprising that women are confused about the recently changed recommendations for cancer screening and prevention. New guidelines from the American College of Obstetricians and Gynecologists (ACOG) – the leading medical group that provides health care for women – say women should wait longer to begin cervical-cancer screening and that they should be screened less frequently. On the heels of similar changes to breast-cancer screening guidelines, it’s understandable that many women might see this as a step backward.

On the contrary, the new cervical-cancer screening recommendations reflect advances in our understanding of this disease and in tools now available to prevent it. More importantly, they present an opportunity to educate women about the significant opportunity we have to further prevent – if not eliminate – cervical cancer.

New ACOG screening guidelines recommend women should begin getting Pap tests at age 21 (as opposed to within three years of becoming sexually active) and that, from ages 21 to 29, most women should have Pap tests every two years instead of annually. Additionally, screening for women 30 and older with a history of normal Pap test results now moves to every three years.

To understand the rationale for these changes, it’s important to first know how the disease develops. Cervical cancer is caused by “high-risk” types of the human papillomavirus (HPV), a common sexually transmitted infection. Most women will have HPV at some point in their lives, but their immune systems will typically clear the virus without symptoms or treatment. HPV infections that persist over time – typically many years – can cause cell changes that can potentially lead to cervical cancer. Because cervical cancer is slow-growing, it generally allows ample time for screening to detect problems that can be treated before the cancer can develop. The majority who die of cervical cancer in the U.S. have either never been screened or have not been screened in many years.

A Pap test is the traditional means of screening for cervical cancer. It involves examining cervical cells under a microscope to detect abnormalities that can then be treated, if necessary. Since its use became widespread 60 years ago, the Pap test has helped to significantly reduce cervical cancer rates. So, if the Pap test has been such a success, why change the guidelines? First, newer research shows that cervical cancer is extremely rare in women under 21. Cervical abnormalities among sexually active girls in this age group are common, but they typically go away on their own. Newer studies, however, show that treatment for these abnormalities that would most likely resolve themselves can cause later pregnancy complications, such as premature birth. This is one instance in which treatment can cause more harm than good. By delaying the start of screening, we can hopefully avoid unnecessary treatment.

The rationale for less-frequent screening is similar. Evidence shows that screening with a Pap test every year does not offer any additional benefit over screening every two or three years. Waiting longer between screenings can help avoid unnecessary treatment of abnormalities that likely will go away on their own.

Also, new technological advances offer women 30 and older – the group most at risk for cervical cancer – more protection against this disease. For these women, an HPV test is now available and uses molecular technology to determine whether HPV is present. An HPV infection that continues for years is what leads to increased risk of developing cervical cancer. If an HPV infection is found, a woman can be monitored more closely by her clinician. A negative HPV test in tandem with a normal Pap test can give a clinician and her patient increased reassurance that the woman is not at risk of developing cervical cancer for at least the next three years. The HPV test also is used for women of all ages to help clarify inconclusive Pap test results. The HPV test is not used routinely in women under 30 because HPV is so common in this age group that a positive HPV test could lead to unnecessary treatment.

While screening is critical to preventing cervical cancer, two HPV vaccines – the first-ever vaccines to fight a cancer – are now FDA-approved and offer significant potential to help reduce cervical cancer rates.

Remember, these new screening recommendations are simply guidelines and that clinicians, in conjunction with patients, need to determine the most appropriate cervical-cancer prevention approach for each woman. These new guidelines provide an opportunity for more conversation on this issue between women and their health-care providers. After all, few things are better for women’s health than educated and empowered patients.
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Wysocki is president and CEO of the National Association of Nurse Practitioners in Women’s Health. Scanlan is chair of the National Council of Women’s Organizations.
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Copyright (C) 2009 by the American Forum. 12/09